Wachusett Manor

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record, and policy review, the facility failed to provide care in accordance with professional standards of practice relative to providing a pressure redistribution cushion (cushion that spreads pressure more evenly across its surface to reduce the amount of pressure on any one part of the body) to a wheelchair when the Resident was at risk for skin breakdown for one Resident (#5) out of a total sample of 19 residents. Specifically, for Resident #5 the facility staff failed to: -Follow a Physician's order to provide a pressure redistribution cushion to the Resident's wheelchair. -Implement the Resident's care plan for a new cushion to the Resident's wheelchair. -Provide a pressure relieving device to the Resident's chair as indicated in the Minimum Data Set (MDS) Assessment and for the Resident who was assessed as being at a high risk for skin breakdown. Findings include: Review of the facility policy titled Support Surface Guidelines, dated September 2013, included: -Review the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide necessary respiratory care and services in accordance with professional standards of practice for one Resident (#43) out of a total sample of 19 residents. Specifically, the facility staff failed to: -verify the Physician orders for the appropriate liter per minute (LPM- the flow rate that supplemental oxygen is set for delivery) of Oxygen when the Resident was ordered for seven (7) LPM of Oxygen. -ensure that Resident #43 was administered the appropriate liter flow for the oxygen delivery device (nasal cannula - a thin flexible tube that provides supplemental oxygen to patients through the nose via nasal prongs) being used when the Resident was found to be ordered for and administered greater than six (6) LPM of Oxygen that was not compliant with professional standards of practice. Findings include: Review of the facility policy titled Oxygen Administration, revised October 2010, indicated the following: -Verify that there is a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that one resident (#71) out of a total sample of 19 residents received trauma-informed care in accordance with professional standards of practice. Specifically, the facility failed to complete a trauma history assessment for Resident #71 who had a diagnosis of Post Traumatic Stress Disorder (PTSD: a mental and behavioral disorder that develops from having experienced a traumatic event, causing flashbacks, nightmares and severe anxiety), placing the Resident at risk for re-traumatization. Findings include: Review of the facility policy titled Trauma Informed and Culturally Competent Care Level III, last revised August 2022, indicated the following: -Purpose: >To guide staff in providing care that is culturally competent and trauma informed in accordance with professional standards. >To address the needs of trauma survivors by minimizing triggers and/or re-traumatization. -Resident Screening: >Utilize initial screening to identify the need for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide dental services for one Resident (#2) out of a total sample of 19 residents. Specifically, the facility staff failed to obtain consent for dental services from Resident #2's Health Care Proxy (HCP- the person chosen as the healthcare decision maker when the individual is unable to do so for themself) in a timely manner after the HCP had been invoked (made active by the Physician). Findings include: Resident #2 was admitted to the facility in May 2022, with diagnoses that included Alzheimer's Disease (a progressive disease beginning with mild memory loss and leading to the loss of the ability to carry on a conversation and respond to the environment, involves parts of the brain that control thought, memory, and language) and lack of coordination. Review of the facility policy for Dental Examination/Assessment, last revised December 2023, indicated: -That each resident will undergo a dental assessment within .90 days of admission.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to maintain resident wheelchairs in a clean and sanitary manner for two Residents (#291 and #293), out of a total sample of 19 residents. Specifically, the facility failed to ensure that: 1. Residents #291's wheelchair was clean, sanitary, and in good repair. 2. Resident #293's wheelchair was clean and sanitary. Findings include: Review of the facility policy titled Cleaning Wheelchairs and Gerichairs (specialized recliners that are upholstered in non-permeable, easily sanitized vinyl), revised 9/5/2017, indicated: -If items (wheelchairs and gerichairs) are the responsibility of Environmental Services, the first step is .arrange to get wheelchairs or gerichairs from the residents at a convenient time for the resident. -Set up a schedule, with input from Nursing, to collect, wash, and dry chairs. -Take chairs to an open area - basement or shower room- use pressure washer or scrub by hand with a brush or sponge and germicide solution. -Rinse thoroughly with water and dry completely with rags. Pay special attention to the seats…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and Facility Assessment Tool review, the facility failed to ensure its staff implemented the Facility Assessment Tool's staff training/education and competencies plan, and updated the Facility Assessment Tool to accurately reflect the resident population and care needs for day-to-day operations and medical emergencies for one Resident (#89) out of one applicably sampled resident with a laryngectomy (removal of the larynx [voice box] resulting in the trachea [airway] being brought to the skin as a stoma [opening] in the front of the neck) tube, out of a total of two discharged residents sampled. Specifically, the facility failed to ensure its staff identified the need for licensed nurse education/training and competencies relative to day-to-day care and emergency care for residents with laryngectomy tubes when Resident #89 was admitted to the facility, and laryngectomy tube care needs were not identified on the Facility Assessment Tool. Findings include: Review of the Facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, document review and interview, the facility failed to ensure its staff implemented an infection prevention and control program to provide a sanitary environment and help prevent the development and transmission of communicable diseases. Specifically, the facility failed to ensure its staff 1. implemented a surveillance plan to identify the potential presence of Legionella (a bacteria that can grow and multiply in moist areas of a building's water system and cause lung infection) within the facility, and 2. implemented the use of personal protective equipment (PPE), to prevent the transmission of infection, while handling soiled linen in the facility laundry room. Findings include: 1) Review of the facility document titled Interim Water Management Program for Legionella Risk Reduction created August of 2017 indicated the following: - each facility must establish a Water Management Team. - the team is responsible for implementing policies and procedures presented in the document. - hot water temperatures should be monitored and recorded daily, flush hot water in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on policy review, record review and interview, the facility failed to ensure its staff maintained a system to track and accurately document staff COVID-19 vaccination status. Findings include: Review of the facility COVID-19 Staff Vaccination Policy, last revised in June 2022 indicated the following: - the infection preventionist maintains a tracking worksheet of staff members and their vaccination status. - the tracking worksheet is the most current vaccination status of all staff who provide any care, treatment or other services for the facility and/or its residents. Review of the COVID-19 Staff Vaccination Status for Providers documentation provided by the Director of Nurses (DON) indicated there were 43 staff who were partially vaccinated for COVID-19, 20 staff were completely vaccinated for COVID-19 and nine staff who were granted non-medical exemptions for the vaccine. Further review indicated there was a total of 72 staff in the facility and 40.3% of the staff were completely vaccinated for COVID-19. Review of the National Healthcare Safety Network (NHSN) information…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure its staff provided an environment as free of accident hazard as possible for four Residents (#34, #56, #72, and #24) out of 24 total sampled residents. Specifically, the facility failed to provide: 1. adequate supervision and assistance for Resident #34 when the Resident with diagnosis of dementia, was being transported to an appointment outside the facility, and exited the transport van on the roadway, 2. adequate assistance to Resident #56 relative to eating when the Resident had dysphagia (difficulty swallowing) and was being physically assisted by a staff member to eat when the staff member was not trained in feeding assistance, 3. a smoking apron for Resident #72 when the facility identified the need for the Resident to wear a smoking apron when he/she actively smoked, 4. a cigarette receptacle within reach for Resident #24 which resulted in the Resident depositing cigarette ashes on the ground while he/she smoked, and 5. adequate supervision for Resident #24 when the Resident gained access to and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure its staff had the required members of the Quality Assessment (QA) and Assurance Committee attended two of the last four quarterly meetings. Specifically, the facility staff failed to ensure the Infection Preventionist (IP) attended, as required. Findings include: Review of the QA Committee Meeting sign-in sheets for July 18, 2022 and October 17, 2022, indicated there was no IP in attendance. During an interview on 5/16/23 at 3:59 P.M., the Administrator reviewed the QA sign-in sheets for July 18, 2022 and October 17, 2022 and said there was no IP in the facility for six months and that was why there was no IP in attendance for those meetings.

Based on policy review, record review and interview, the failed to ensure its staff maintained medical records that included documentation indicating that the Resident or Resident's Representative, had been provided education regarding the benefits and potential side effects of the COVID-19 vaccine, declined the vaccine or was administered the COVID-19 vaccine. Specifically, the facility staff failed to document the COVID-19 immunization status for four Residents (#34, #30, #63, and#82), out of five applicable sampled residents, in a total sample of 24 residents. Findings include: Review of the facility COVID-19 Vaccination of Residents Policy, last revised in June 2022, indicated the following: - each resident is offered the COVID-19 vaccine . - the resident or resident representative has the opportunity to accept or refuse a COVID-19 vaccine and to change his/her decision. - before the COVID-19 vaccine is offered, the resident is provided with education regarding the benefits, risks and potential side effects associated with the vaccine. - the resident's medical record includes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview the facility failed to ensure its staff provided a dignified environment for one Resident (#4) out of 24 sampled residents. Specifically, the facility staff failed to remove a bedpan, with feces in it, from the Resident's bed side table, that also had drinks for consumption on it. Findings include: Resident #4 was admitted to the facility in March 2023. On 5/7/23 at 9:33 A.M., the surveyor observed the Resident in bed, watching TV. The bed side table had a bed pan with feces in it and a covered drink next to it, on the bed side table. The surveyor observed Staff #2 enter the Resident's room and ask the Resident which nutritional supplement drink he/she preferred. Resident #4 answered and Staff #2 left the room to get the drink. The surveyor observed Staff #2 re-enter the Resident's room and place the drink next to the bed pan. Staff #2 left the room. During an interview on 5/7/23 at 9:34 A.M., the Resident said that sometimes the bed pan was left on the bed side table for hours and he/she did not like the smell of it. During an interview on 5/9/23…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview the facility failed to ensure its staff notified the Physician in a timely manner, of Hospice recommendations related to pain and mood management, for one Resident (#88) out of 24 sampled residents. Findings include: Resident #88 was admitted to the facility in March 2023 with diagnosis including acute and chronic respiratory failure. Review of the April 2023 Physician's orders indicated to admit to Hospice services on 4/12/23. Review of a Hospice Note, dated 4/27/23, indicated a recommendation to increase Ativan (anti-anxiety) to 0.5 milligrams (mg) by mouth at bedtime. Review of a Hospice Note, dated 5/2/23, indicated a recommendation to increase frequency of Morphine Sulfate (narcotic analgesic) to 5 mg sublingual (under tongue) every 4 hours (scheduled). Review of a Hospice Note, dated 5/4/23, indicated a recommendation for Ativan 1mg sublingual every 6 hours (scheduled). Review of the progress notes did not indicate any evidence that the Physician was notified of the Hospice recommendations made on 4/27/23, 5/2/23, or 5/4/23. Review of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure its staff completed Significant Change in Status Assessments (SCSA) for two Residents (#88 and #22) out of 24 sampled residents, when they entered into Hospice services. Findings include: 1. Resident #88 was admitted to the facility in March 2023. Review of the April 2023 Physician's orders indicated to admit to Hospice services on 4/12/23. Review of the Minimum Data Set (MDS) assessments indicated the SCSA was not initiated until 5/7/23. During an interview on 5/9/23 at 11:01 A.M., the MDS Coordinator said she initiated the SCSA when it was found during an audit that was done during that weekend. She said she thought the Resident had just signed on to Hospice services and if she had known the Resident was on Hospice services in April, she would have done the significant change assessment at that time. Refer to F 657 2. Resident #22 was admitted to the facility in November 2014. Review of Resident #22's Nursing Progress Note, dated 1/31/23, indicated the Resident was admitted to Hospice services on 1/27/23. Review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure its staff completed discharge Minimum Data Set (MDS) assessments for two Residents (#59 and #46), as required, out of 24 total sampled residents. Specifically, facility staff failed to complete discharge MDS assessments for: 1. Resident #59 when he/she was discharged home from the facility, and 2. Resident #46 when he/she was discharged from the facility to another facility. Findings include: 1. Resident #59 was admitted to the facility in December 2022. Review of Resident #59's Nursing Progress Note, dated 12/30/22 indicated the Resident was discharged home with medications and belongings. Review of Resident #59's clinical record indicated no evidence a discharge MDS assessment was completed, as required. 2. Resident #46 was admitted to the facility in December 2022. Review of Resident #46's Nursing Progress Note, dated 1/12/23, indicated the Resident was discharged to a different facility that day. Review of Resident #46's clinical record indicated no evidence a discharge MDS assessment was completed, as required.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure its staff accurately coded Minimum Data Set (MDS) assessments for three Residents (#58, #72, and #22) out of 24 total sampled residents. Specifically, facility staff failed to accurately code: 1. Resident #58 for wandering behavior on one comprehensive MDS assessment when the Resident demonstrated wandering during the observation period while at the facility, 2. Resident #72 as having current use of tobacco on one comprehensive MDS assessment when the Resident actively smoked during the observation period while in the facility, and 3. Resident #22 as using oxygen on one quarterly MDS assessment when the Resident used oxygen during the observation period while at the facility. Findings include: 1. For Resident #58, facility staff failed to accurately code wandering behavior on one MDS assessment, dated 8/1/22, when the Resident demonstrated wandering behavior during the observation period at the facility. Resident #58 was admitted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure its staff implemented the plan of care for one Resident (#38), out of 24 total sampled residents, relative to meal intake. Specifically, the facility staff failed to encourage the Resident to consume food, during two consecutive breakfast meals, when the Resident did not initiate self-feeding. Findings include: Resident #38 was admitted to the facility in May 2022 with diagnoses including dementia, cognitive communication disorder, and oral phase dysphagia (difficulty coordinating chewing and swallowing food placed in the mouth). Review of Resident #38's Nutrition Care Plan, initiated 8/10/22, included: Encourage greater than 50% fluid and food consumption. On 5/7/23 from 8:58 A.M. through 9:15 A.M., the surveyor observed Resident #38 seated at a table in the Unit Three Dining Room. There was a three-section divided plate on the table in front of the Resident with two sections containing pureed food. There was a covered bowl of hot cereal to the right of the Resident's plate with a small, covered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure its staff 1. reviewed the comprehensive care plan with the Resident/Resident Representative at least quarterly, for one Resident (#24), 2. and failed to revise the comprehensive care plan for one Resident (#22) after admission to Hospice services secondary to a significant change in health status, out of 24 sampled residents. Findings include: 1. For Resident #24 the facility failed to ensure its staff included the Resident/Resident Representative in the quarterly interdisciplinary team (IDT) care plan meetings. Review of the clinical record did not indicate any evidence of care plan meeting notes since 9/1/22. During an interview on 5/8/23 at 10:46 A.M., Social Worker #1 said they usually entered the care plan meeting notes in the Resident's clinical record. During an interview on 5/8/23 at 12:41 P.M., Unit Manager (UM) #2 said she could not find any care plan meeting notes since 9/1/22. She said the care plan had been reviewed but she could not provide any evidence of care plan meetings with the Resident/Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interview, the facility failed to ensure its staff offered a preferred activity of choice, based on the comprehensive assessment and care plan, for one Resident (#4) out of 24 sampled residents. Specifically, the facility failed to ensure its staff offered the Resident to go outside when the Resident communicated desire to go outside. Findings include: Resident #4 was admitted to the facility in March 2023. Review of the Minimum Data Set (MDS) assessment, with Assessment Reference Date (ARD) of 4/1/23, indicated the Resident had moderate cognitive impairment as evidenced by a score of 12 out of 15 on the Brief Interview for Mental Status (BIMS). Review of the care plan for activities, initiated 4/6/23, indicated the goal was for the Resident to engage in activities of interest daily. The interventions included, but were not limited to, the following: -The Resident loves to go outside to get fresh air when the weather is good. Review of the care plan for Activities of Daily Living (ADL), with goal date of 7/17/23, indicated the Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure its staff provided vision services for one Resident (#41) out of 24 sampled residents. Findings include: Resident #41 was admitted to the facility in March 2021 with diagnosis including Diabetes Mellitus. Review of the clinical record indicated the Resident signed a consent for ancillary eye care services on 3/15/21. Further review of the record did not indicate any evidence of visits from eye care services. Review of the Minimum Data Set (MDS) assessment, with Assessment Reference Date (ARD) of 3/7/23, indicated the Resident had no cognitive impairment as evidenced by a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS) and the Resident had adequate vision with the use of corrective lenses. During an interview on 5/9/23 at 10:44 A.M., the Resident told the surveyor that he/she had been asking to see the Physician so he/she could get an eye exam. The Resident said his/her glasses needed to be checked. During an interview on 5/9/23 at 1:51 P.M., Unit Manager (UM) #2 said the Resident has signed up…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observations and interviews, the facility failed to ensure its staff evaluated the nutritional needs in a timely manner for one Resident (#75) out of one applicable sampled resident in a total sample of 24 residents, who was receiving oral food and feedings via gastrostomy (G-tube: an opening in the abdominal wall, made surgically for the introduction of food) tube. Specifically, the facility failed to ensure timely communication with the Registered Dietician (RD) to assess one Resident (#75) for an increase in G-tube feeding when the Resident had a history of weight loss, accepted limited food by mouth, and the Physician recommended the RD to assess the Resident for potential increase in G-tube feeding. Findings include: Resident #75 was admitted to the facility in April 2023 with diagnoses including severe protein-calorie malnutrition (an imbalance between the nutrients your body needs to function and the nutrients it gets), anorexia nervosa (an eating disorder causing people to obsess about weight and what they eat) and dysphagia (difficulty swallowing).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on policy review, observation, record review and interview, the facility failed to ensure its staff provided care for a peripherally inserted central catheter (PICC-catheter that enters the body through the skin and extends into the superior vena cava, to deliver medications for extended periods of time), for one Resident (#142), out of one applicable sampled residents, in a total sample of 24 residents. Specifically, the facility failed to ensure its staff entered Physician orders for care and services of the PICC onto the Medication Administration Record (MAR)/Treatment Administration Record (TAR) to ensure the nursing staff implemented the care as ordered. Findings include: Review of the facility's policy for Central Venous Catheter Care and Dressing Changes, dated March 2022, indicated the following: -The purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter related infections that are associated with contaminated, loosened, soiled, or wet dressings. -Perform site care and dressing change at established intervals or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on policy review, observation, record review and interview, the facility failed to ensure its staff provided adequate pain management for one Resident (#88) out of 24 sampled residents. Specifically, the facility failed to follow through, in a timely manner, with recommendations for pain management from the Hospice provider and failed to administer as needed (PRN) analgesic when pain was identified. Findings include: Review of the facility's policy for Pain, dated March 2018, indicated the following: -If a consultant is involved in managing pain, the attending physician will maintain an active role by reviewing the consultant's recommendations, addressing medical issues that affect pain, monitoring for complications related to treatment, and evaluating subsequent progress. Resident #88 was admitted to the facility in March 2023 with diagnosis including acute and chronic respiratory failure. Review of the April 2023 Physician's orders indicated to admit to Hospice services on 4/12/23. Review of the care plan for pain, with goal date of 7/7/23, indicated an intervention to:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on policy review, observation, record review and interview, the facility failed to ensure its staff assessed one Resident (#4) out of 24 sampled residents, for the risk of entrapment from bed rails prior to installation. Findings include: Review of the facility's policy for Bed Safety and Bed Rails, dated August 2022, indicated the following: -The resident assessment to determine risk of entrapment includes, but is not limited to: *medical diagnois, conditions, symptoms, and/or behavioral symptoms: *size and weight *sleep habits *medication (s) *acute medical or surgical interventions *underlying medical conditions *existence of delirium *ability to toilet self safely *cognition *communication *mobility (in and out of bed) *risk of falling Resident #4 was admitted to the facility in March 2023. On 5/8/23 at 12:29 P.M., the surveyor observed the Resident in bed, on an air mattress, watching TV, with bilateral quarter bed rails in the raised position. On 5/9/23 at 10:23 A.M., the surveyor observed the Resident in bed, on an air mattress, watching TV, with bilateral quarter bed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure its staff provided required Physician visits within the first 90 days of admission to the facility for two Residents (#26 and #35) out of 24 total residents sampled. Specifically, facility staff failed to ensure Residents #26 and #35 received Physician visits at least every 30 days during their first 90 days of admission to the facility. Findings include: 1. Resident #26 was admitted to the facility in June 2022. Review of Resident #26's clinical record indicated the Resident received Physician visits on: 6/11/22, 6/17/22, 6/25/22, 8/26/22, and 9/12/22. Further review of Resident #26's clinical record included no evidence the Resident received any Physician visit in July 2022, as required. 2. Resident #35 was admitted to the facility in July 2022. Review of the clinical record indicated the Resident received visits from the Nurse Practitioner on 7/19/22, 7/25/22, 8/2/22, and 8/18/22. Further review of the clinical record did not indicate any evidence that the Resident received a Physician's visit in September 2022,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure its staff updated one Resident's (#142) paper clinical record, related to the Advanced Directive order in a timely manner, to reflect the Resident's wishes to have Cardiac Pulmonary Resuscitation (CPR) administered in the event of cardiac or respiratory arrest, out of 24 sampled residents. Findings include: Resident #142 was admitted to the facility in [DATE]. Review of the paper clinical record indicated a Massachusetts Order for Life Sustaining Treatment (MOLST), dated [DATE], with directives that during a cardiac or respiratory arrest, Do Not Resuscitate (DNR), Do Not Intubate (DNI) and Do Not Transfer to Hospital (DNH)- unless needed for comfort). Review of the [DATE] Physician's orders indicated an Advanced Directives order for Full Code (CPR in the event of a cardiac or respiratory arrest), dated [DATE]. During an interview on [DATE] at 9:25 A.M., Unit Manager (UM) #2 said the process was that if a resident coded (respiratory or cardiac…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on policy review, record review and interview, the facility failed to ensure its staff maintained medical records that included documentation indicating that the Resident or Resident's Representative, had been provided education regarding the benefits and potential side effects of the pneumococcal vaccine, declined the vaccine or was administered the pneumococcal vaccine. Specifically, the facility staff failed to document the pneumococcal immunization status for two Residents (#76 and #63), out of five applicable sampled residents, in a total sample of 24 residents. Findings include: Review of the facility pneumococcal vaccine policy, last revised March of 2022, indicated the following: - all residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections - assessments of pneumococcal vaccination status are conducted within five working days of the resident's admission if not conducted prior to admission. - before receiving the pneumococcal vaccine, the resident or legal representative receives information and education regarding the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interview, the facility failed to ensure its staff completed an inspection of bed rails, to identify areas of possible entrapment, for one Resident (#4) out of 24 sampled residents. Findings include: Resident #4 was admitted to the facility in March 2023. On 5/8/23 at 12:29 P.M., the surveyor observed the Resident in bed, on an air mattress, watching TV with bilateral quarter bed rails in the raised position. On 5/9/23 at 10:23 A.M., the surveyor observed the Resident in bed, on an air mattress, watching TV with bilateral quarter bed rails in the raised position. Review of the care plan, indicated an intervention for two quarter bed rails to aid in bed mobility, initiated on 4/3/23. During an interview on 5/10/23 at 9:54 A.M., the Maintenance Director said when the staff got an order for bed rails, he was the person who installed them. He said he explained the use of the bed rails to the residents, then enters a record of the installation electronically. The surveyor requested the assessment related to potential entrapment from bed rails for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.